Family Court Of The State Of New York County Of (Page 3 of 9) in pdf

Form 4-SM-3 page 3

10. a. Health insurance coverage for the children is ordered as follows:

G Petitioner is directed to continue the health insurance coverage for the following

child(ren) [specify]:

with costs to be allocated between the parties as follows [specify]:

G Petitioner is directed to enroll the following child(ren) [specify]:

in the above-named health insurance plan, effective [specify date]:

with costs to be allocated between the parties as follows [specify]:

G Respondent is directed to continue the health insurance coverage for the following

child(ren) [specify]:

with costs to be allocated between the parties as follows [specify]:

G Respondent is directed to enroll the following child(ren) [specify]:

in the above-named health insurance plan, effective [specify date]:

with costs to be allocated between the parties as follows [specify]:

G The custodial parent [specify]:

shall immediately apply to

enroll the child(ren) in the NYS "Child Health Plus Program" or the New York State

Medical Assistance Program or the publicly funded health insurance program in the State

where the custodial parent resides, it is hereby. If the children are accepted into the "Child

Health Plus Program," the cost of the premiums or family contribution shall be allocated

among the parties as follows:

b. The allocation between the parties of costs of medical premiums or contributions in ¶a :

G is prorated in the same proportion as each parent’s income is to the combined parental

income.

G is not prorated in the same proportion as each parent’s income is to the combined

parental income, because that would be unjust or inappropriate for the following

reason(s) [specify]:

The following factors were considered in determining the allocation in ¶a [specify]:

11. The custodial parent's pro rata share of the basic child support obligation is:

G ordered without deviation;

G would be G unjust G inappropriate, based upon consideration of the following factor(s)

in Family Court Act §413(l)(f) [specify factor(s) and reason(s)]:

13. [Applicable only where the parties have agreed or stipulated to an order of child support,

pursuant to Family Court Act §413(1)(h)]:

G The parties have voluntarily stipulated to child support for the following

child(ren)[specify]:

payable by [specify]:

to [specify]:

in the amount of $ ______ G weekly G every two weeks G monthly

G twice per month G quarterly, such stipulation having been entered into the record and

reciting, in compliance with Section 413(l)(h) of the Family Court Act that:

a. The parties have been advised of the provisions of Section 413(l) of the Family Court

Act;

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